Ragab and Al-Mazroua, Pediat Therapeut 2015, 5:1 DOI: 10.4172/2161-0665.1000220

Open AccessResearch Article

Volume 5 • Issue 1 • 1000220Pediat TherapeutISSN: 2161-0665 Pediatrics, an open access journal

Pattern of Pediatric Toxicity in Saudi Arabia-Eastern Province (Incidence, Demographics and Predisposing Factors)Ahmed Refat Ragab1* and Maha Khalid Al-Mazroua2

1Department of Forensic Medicine and Clinical Toxicology, Mansoura University, Egypt2Dammam Poison Control Center, Eastern Region, Saudi Arabia

AbstractChildhood poisoning is a major cause of morbidity in both developing and developed countries. In spite of the

success of some interventions to prevent accidental poisoning in the pediatric population, toxic ingestions continue to be a common occurrence. The purpose of this study was to shed light on the problem of accidental poisoning among children, to determine the factors related to accidental poisoning by the most common medications and household agents in poisoned patients who were visited a pediatric ER department. A prospective study was conducted in the period from January 2011 until December 2013 at the Dammam Maternal and Child Hospital. The studied children were a mix of boys and girls, did not suffer from any mental disabilities, were aged below 15 years old, and were of variable nationalities. The findings of the study demonstrated that the most common toxic presentation in the reported cases were medications toxicity exposure (63.2%) followed by pesticides toxic exposures (16.3%). Acetaminophen exposure represents the most common toxic forum of medication exposures (27.6%). Age from 1-7 year is the most common vulnerable age of toxicity (74.8%). The most common pharmaceutical preparation involved in the toxic presentation was tablets and syrup forum 41.7% and 20.7% respectively. From the studied cases 64.5% of the reported cases were asymptomatic toxic presentation, and on the opposite site 6% were suffered from acute severe consciousness disturbance “Glasgow Coma Scale was less than 8”. Effective health promotion programs for parents and careers regarding poisoning hazards are needed to increase awareness and reduce the incidence of poisoning among children.

*Corresponding author: Ahmed Refat Ragab, Department of Forensic Medicineand Clinical Toxicology, Faculty of Medicine, Mansoura University, Egypt, Tel:00966540990033; E-mail: ahmedrefat1973@yahoo.com

Received June 25, 2014; Accepted November 13, 2014; Published November 15, 2014

Citation: Ragab AR, Al-Mazroua MK (2015) Pattern of Pediatric Toxicity in SaudiArabia-Eastern Province (Incidence, Demographics and Predisposing Factors).Pediat Therapeut 5: 220. doi:10.4172/2161-0665.1000220

Copyright: © 2014 Ragab AR, et al. This is an open-access article distributedunder the terms of the Creative Commons Attribution License, which permitsunrestricted use, distribution, and reproduction in any medium, provided theoriginal author and source are credited.

Keywords: Poisoning; Children; Incidence; Saudi Arabia

Introduction The incidence of acute poisoning in both developed and developing

countries is increasing all over the world during the last few years. This makes the problem of childhood poisoning very likely to get much worse [1].

Acute poisoning in children is still an important public health problem and represents a frequent cause of admission in emergency units. Homes are the place meant to be safe and secure. However, home accidents are the most frequent causes of injury. This gives the impression that homes are not so safe as one may think [2].

Low social standard and high social mobility increase the likehood of accidental poisoning since safe keeping of toxic preparations is not followed, parents are likely to be less knowledgeable about the risks, supervision may be less strict and in disturbed families hunger may be stimulus to ingestion of harmful substances [3].

The epidemimiological surveillance specific for each country is necessary to determine the extent and characteristics of the problem, according to which related preventive measures can be taken [4].

Accidental poisoning in the children is a complex interaction between the child, a hazardous substance and certain environmental factors. Negligence of parents or caretakers can cause an accidents and poisoning in children, which may be of fatal consequences to the child [5,6].

The purpose of this study was to shed light on the problem of accidental poisoning among children, to determine the factors related to accidental poisoning by the most common medications and household agents and finally to describe the epidemiology, pattern, severity of poisoning and the results of treatment of poisoned patients who were visited a pediatric section in Dammam Maternal and Child Hospital.

Subjects and MethodsStudy setting

This work was conducted as a prospective (Electronic medical Review) EMR database review study analysis of all acute poisoning and accident cases, who were visited and/or admitted in PICU and or children ward of Dammam MCH with referral sample and electronic consultation at Dammam Regional Poison Control Center-Eastern Region, KSA.

Inclusion and exclusion criteria

Pediatric patients less than 15 years old for suspected toxicity in (Dammam MCH) that were in a three year-long period from the beginning of January 2011 until the end of December 2013. Acute food poisoning patient were excluded from research group

Study population parameters

All clinical reported data and laboratory and non-laboratory Investigations were noted down important and detailed information of all the patients, like their age, sex, nationality, time of poisoning, date of poisoning, route of poisoning, form of poisoning category of poisoning as well as type of medications.

Pedi

atrics & Therapeutics

ISSN: 2161-0665

Pediatrics & Therapeutics

Citation: Ragab AR, Al-Mazroua MK (2015) Pattern of Pediatric Toxicity in Saudi Arabia-Eastern Province (Incidence, Demographics and Predisposing Factors). Pediat Therapeut 5: 220. doi:10.4172/2161-0665.1000220

Page 2 of 4

Volume 5 • Issue 1 • 1000220Pediat TherapeutISSN: 2161-0665 Pediatrics, an open access journal

Grouping of the studied patients

The studied cases were divided into 3 groups according to the age of the studied cases as follows:

Group A: less than one year

Group B: from one to less than seven years «Age of discrimination”.

Group C: from seven to less than fifteen years.

Electronic Medical Records Review ProcessThree reviewers conducted the entire review process. Taking the

help of individual patient record, the child Online Toxicology Analytical Request and Result “OTARR” electronic records were accessed by way of medical record number access into the EMR. Predefined data points fed into a standard type Excel worksheet was set up on a share drive that was password protected which was to be used by ever single reviewer in order to get abstraction of data.

Then every patient was reviewed on an independent basis to be reviewed for agreement purpose followed by checks carried out by the third reviewer to see if there were still any other discrepancies identified. Data extractors had to have total agreement amongst themselves.

The study was approved by Medical Ethics Committee of the Dammam Regional Poison Control Center.

Statistical AnalysisThere was a statistical analysis of the entire data with help of the

present SPSS statistical package Version 19.0. Chi square, Pearson correlation analysis and variance analysis were employed in the analysis of the data. This data was further presented as mean ± Standard Deviation (SD). Approval of local ethical committee was obtained related with this research.

ResultsThe current work comprised of 1272 pediatric patients (673 males

and 139 females with age SD: 3.9 ± 3.6 years). During the same period a total 5838 case were referred to Dammam Regional Poisoning Control Center for toxicological consultations and investigations. So the pediatric toxicity represents more than 1/5 of the total toxicological emergencies received by Dammam Regional Poisoning Control Center (Table 1).

The most common toxic presentation in the reported cases were medication toxicity exposure (63.2%) followed by pesticides toxic exposures (16.3%). Acetaminophen exposure represents the most common toxic forum of medication exposures (27.6%) (Table 2, Figure 1).

Age from 1-7 year is the most common vulnerable age of toxicity (74.8%). Regarding nationality, Saudi children consumed the most common toxic presentation (89.9%). To refer the diurnal and nocturnal pattern of presentation the peak of toxic presentation was started at 1 pm to 11 pm (Table 1, Figures 1 and 2).

The most common pharmaceutical preparation involved in the toxic presentation was tablets and syrup forums 41.7% and 20.7% respectively. From all studied cases a 64.5 % of the reported cases were asymptomatic toxic presentation, and on the opposite site 6% were suffered from acute severe consciousness disturbance «Glasgow Coma Scale was less than 8» (Figure 3).

Summer months showed a significant increase in the number of the presenting samples than winter months. The most presenting

symptoms in the current research were GIT upset vomiting (24.9%) and abdominal (pain 10.3%), followed by neurological disturbances, convulsion (12.3%) and Irritability (8.6%). As regard to interval between the time of poisoning and arrival time to the ER was 3.7 ± 3.4 hours (Figures 4 and 5).

Ace

taminophen

Unkown M

edciations

NSAI

Carbamezapine

Cold preparations

Metcloprbamine

Antiepiletics

Insecticid

es

Multivitamins

Oral Contra

ceptive

Pills

Antibiotics

Omeprazole

B-Stimulants

Antihypertensiv

e

Salicylates

Ca Channel Blocke

r

Methotrexa

te

B-Blocker

Benzodiazepines

Anticholin

ergic

27.6

23.1

9

6.6 6.6 65.1 4.8 4.2 3.9 3.3

2.4 2.1 1.8 1.5 1.5 1.5 1.2 0.9 0.6

%

Figure 1: Percentage distribution of variable medications from exposure toxicities in the studied cases.

Age mean ± SD 3.9 ± 3.6 years Age Category No %

Less Than One Year 58 4.6From One to less than Seven Years 952 74.8From Seven to less than Fifteen Years 262 20.6

Sex Male 673 52.9Female 599 47.1

NationalitySaudi 1143 89.8Non-Saudi 129 10.2

Admission StatusAdmitted 720 56.6Non-admitted 552 43.4

Degree of toxicityNo Toxicity 821 65Mild Degree of Toxicity 207 16.3Moderate Degree of Toxicity 186 14.7Severe Degree of Toxicity 58 4

Table 1: Demographic and medical assessment characters of the studied cases.

Parameter No %Poison Type

Drug Medications 333 63.2Substance of abuse 20 3.8Pesticides 86 16.3Metals 4 0.8Caustics 2 0.4Gases 1 0.2Perfumes 12 2.3Hydrocarbon ingestions 9 1.7Herbal medications 4 0.8Unknown 56 10.6

Type of Pesticides Organophosphate Poisoning 41 48.2Permethrin and Pyrethroid Poisoning 15 17.6Warfain Poisoning 29 34.1

Table 2: Percentage distribution of variable toxic agents.

Citation: Ragab AR, Al-Mazroua MK (2015) Pattern of Pediatric Toxicity in Saudi Arabia-Eastern Province (Incidence, Demographics and Predisposing Factors). Pediat Therapeut 5: 220. doi:10.4172/2161-0665.1000220

Page 3 of 4

Volume 5 • Issue 1 • 1000220Pediat TherapeutISSN: 2161-0665 Pediatrics, an open access journal

received over 3 year period from overall number 5838 case toxicological consultation reports.

Acute poisoning is one of the critical causes of ER admissions. Detection and reporting of epidemiological aspects were consisted of great concern to line the strategy of prevention and treatment measures. Dammam Maternal and Child Hospital is the biggest hospital in Dammam City. In this study, the mean age in the studied cases was 3.9 ± 3.6 year, on contrast with our result; there was a low mean age from the current research as research done by Kheja [7] who found the mean age in male and female percentage were 2.97 ± 3.33 and 2.86 ± 2.69. Add to this report another higher mean age then reported in the current research were found in the study done by Sabiha [8] who reported the mean age of the studied children were 5.35 ± 3.1. The variance by increase or decrease from the current research in the mean age may be attributed to small sample size of the comparative research as 147 and 218 reported cases respectively. In this age less than four years old, putting small foreign objects like drugs into mouth by children can cause poisoning.

The most common form of pediatric toxic exposure was adult medication exposure in concise with the previous mention results Burghardt et al. [6] who clarified that adult medication exposures were significantly associated with exposures and poisoning in children of all ages. Across, medications, the greatest risk was among children 0-5 years old. Hypoglycaemics and B-blockers were highest events (60.1% and 35.2%, respectively). Also, same conclusion were detected by Khajeh et al., and Sabiha et al., who represent the incidence of medication toxicity in their published research as (37.4%, 48.4%) [7,8]. On the opposite site to our finding Raed et al., found in their study in Alexandria-Egypt, is the most common form of poisoning in pediatric cases was household poisoning 60.2% in comparison to adult medication poisoning 23.4% [9]. Paracetamol was the most common drugs. This is may be due to the publicity of the drug between all family members and placing the drug in easily accessible places.

In this study the percentage of male/female ratio was 1.2. Andrian and Sarikayalar detect that in 489 poisoning cases were more frequent in male especially in age group less than 10 years. Similar finding have been reported from developed and developing countries [10].

In the current study; about 66% were non-toxic or mild toxic exposure status. In oppsite of our results Al-Hazmi reported in his study of accidental toxic exposure in the children of Jeddah city; he found that only about 7% of the studied cases were reported as nontoxic exposure while 93% were admitted as toxic exposure in a period between January 1994 to December 1996. We may attributed the difference between two figures may be attributed to filtration of cases severity by primary health unit before transfer to secondary care hospital in Dammam and Jeddah.

As in the literature, our research revealed that the most common (75.5%) route was the ingestion of poison. Non-steroidal anti-inflammatory, one of the common modalities in the treatment of painful complains and hyperthermia was the second common cause of drug related poisonings. Also the most presenting symptoms in the current research were GIT upset vomiting (24.9%). The previous mentions results were in a harmony with multiple research results [11-14].

Conclusion and RecommendationsSmall children are curious; they explore everything and put it in

mouth; so all medicine or poisons should be put in cupboard lock up. Accidental poisoning is common in the pediatric age group. Poison

DiscussionIn the current research about 1272 pediatric case consultation were

1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24

%3.9

1.7 1.6 1.31.2

2.02.5

1.72.0

2.82.8

5.4

8.8

6.9

6.8

5.6

4.65.1

6.15.7

5.1

6.8

8.6

.9

Figure 2: Pediatric case presentation percentage over the daily 24 hours.

Tablets

Syrup

Efferev

esce

nt Gran

ules

Suspen

sion

Capsu

les

Supposotorie

s

Injectio

ns

Aeroso

l Spry

Lotions

Inhalar

Cream

Effulsi

ons

Paints

Ointmen

t

Gargles

Unknown

41.7

20.7

2.0 1.7 1.5 1.4 1.2 1.1 .9 .9 .6 .6 .3 .2 .2

25.2

%

Figure 3: Variable pharmaceutical preparations forms in the studied toxic cases.

January

February

March AprilMay

June July

September

October

November

DecemberAugust

6.1 5.9

10.7

8.18.8

6.7

8.0

10.1

9.1

11.1

7.5 7.5

%

Figure 4: Monthly distribution of pediatric case presentation.

Vomiting

Convulsio

n

Variable ty

pes of d

ysryth

mia

Abdonimal P

ain

Irrita

bility

Depressed m

ode

Diarrhea

Constrict

ed Pupil

Hallucin

ation

Agitati

on

Dilated Pupil

Electrolyt

es Abnorm

alities

Tachya

rrthmia

Aggressi

ve

Bradydysa

rrytm

ia

%

Figure 5: Percentage of symptomatic presentation in the studied pediatric cases.

Citation: Ragab AR, Al-Mazroua MK (2015) Pattern of Pediatric Toxicity in Saudi Arabia-Eastern Province (Incidence, Demographics and Predisposing Factors). Pediat Therapeut 5: 220. doi:10.4172/2161-0665.1000220

Page 4 of 4

Volume 5 • Issue 1 • 1000220Pediat TherapeutISSN: 2161-0665 Pediatrics, an open access journal

and medicine should not be put together in same place/self. Small infants should not be left unattended. Parents and the teacher should understand psychology of the child and behave accordingly. Also, the magnitude of the problem of accidental poisoning all over KSA should be studied on a national basis. Finally; the use of warning Design Label on dangerous substances, which should be on national basis and children should be warred and educated not to touch.

Acknowledgment

No funding or sponsorship was received for this study. Dr. Ahmed Refat Ragab is the guarantor for this article, and take responsibility for the integrity of the work as a whole.

Conflict of Interest

Ahmed R. Ragab and Maha K. Al-Mazroua, declare no conflict of interest.

Compliance with Ethics Guidelines

This article does not contain any studies with human or animal subjects performed by any of the authors.

Open Access

This article is distributed under the term of the Creative Commons Attribution Noncommercial License which permits any noncommercial use, distribution, and reproduction in any medium, provided the original author(s) and the source are credited.

References

1. Bicer S, Sezer S, Cetindag F, Kesikminare M, Tombulca N, et al. (2007)Evaluation of acute intoxications in pediatric emergency clinic in 2005. Marmara Medical J 20: 12-20.

2. Mintegi S, Fernández A, Alustiza J, Canduela V, Mongil I, et al. (2006)Emergency visits for childhood poisoning: a 2-year prospective multicentersurvey in Spain. Pediatr Emerg Care 22: 334-338.

3. Burillo-Putze G, Munne P, Dueñas A, Pinillos MA, Naveiro JM, et al. (2003)National multicentre study of acute intoxication in emergency departments ofSpain. Eur J Emerg Med 10: 101-104.

4. Andiran N, Sarikayalar F (2004) Pattern of acute poisonings in childhood inAnkara: what has changed in twenty years? Turk J Pediatr 46: 147-152.

5. Ozdogan H, Davutoglu M, Bosnak M, Tutanc M, Haspolat K (2008) Pediatricpoisonings in southeast of Turkey: epidemiological and clinical aspects. HumExp Toxicol 27: 45-48.

6. Burghardt LC, Ayers JW, Brownstein JS, Bronstein AC, Ewald MB, et al. (2013) Adult prescription drug use and pediatric medication exposures and poisonings. Pediatrics 132: 18-27.

7. Khajeh A, Narouie B, Noori N, Emamdadi A, Ghasemi Rad M, et al. (2012)Pattern of Acute Poisoning in childhood and relative Factors in Zahedan,Southeast Iran. Shiraz E-Medical Journal 13: 3.

8. Sahin S, Carman KB, Dinleyici EC (2011) Acute poisoning in children; data of a pediatric emergency unit. Iran J Pediatr 21: 479-484.

9. Raed M, Mohamed TE, Ramadan F, Hoda FA, Amr SM (2012) Risk factorsof acute poisoning among children: A Study at poisoning unit of a universityhospital in Egypt. South East Asia Journal of Puplic Health 2: 41-74.

10. Tsalkidis A, Vaos G, Gardikis S, Kambouri K, Tripsianis G, et al. (2010) Acutepoisoning among children admitted to a regional university hospital in Northern Greece. Cent Eur J Public Health 18: 219-223.

11. Al Hazmi AM (1998) Patterns of accidental poisoning in children in Jeddah,Saudi Arabia. Ann Saudi Med 18: 457-459.

12. Bhattarai MD, Singh DL, Chalise BS, Koirala P (2006) A case report andoverview of organophosphate (OP) poisoning. Kathmandu Univ Med J (KUMJ) 4: 100-104.

13. Kelly NR, Drutz JE (2012) Prevention of poisoning in children.

14. Bronstein AC, Spyker DA, Cantilena LR Jr, Green JL, Rumack BH, et al. (2010) 2009 Annual Report of the American Association of Poison Control Centers’National Poison Data System (NPDS): 27th Annual Report. Clin Toxicol (Phila) 48: 979-1178.